| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.121(c)(3) | No Immunizations are included on 10/15/24 exam. | Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | On 4/9/2025, the life sharer provider dropped the correct physical form to the PCP that included individual #1s immunization record. |
05/07/2025
| Implemented |
| 6500.121(c)(12) | No Physical Limitations are included on 10/15/24 exam. | The physical examination shall include: Physical limitations of the individual. | On 4/9/2025, the lifesharer dropped the correct physical form to the PCP for completion of physical limitations question. |
05/07/2025
| Implemented |
| 6500.121(c)(14) | No Medical Information pertinent to diagnosis and treatment in case of an emergency was included on 10/15/24 exam. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | On 4/9/2025, the lifesharer provider dropped the correct physical form to the PCP for completion of information pertinent to diagnosis and treatment in case of an emergency question. |
05/07/2025
| Implemented |
| 6500.151(e)(13)(i) | Individual # 1's assessment dated 11/18/24 indicates that he is on a "low salt, low sugar diet", however in the same assessment under the lifetime medical history, it reads that he has a "regular diet". The assessment has internal contradictions. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: Health. | On 4/1/2025, the lifesharer provider contacted the PCP to clarify the dietary recommendations for individual #1 and received a letter with current dietary recommendation healthy diet which includes fruit, vegetables, whole grains, protein, and recommended to keep calories below 1800 per day. The individual assessment and LMH were reviewed, and discrepancies were reconciled to ensure that both documents match individuals' #1 diet recommendation of healthy diet which includes fruit, vegetables, whole grains, protein, and recommended to keep calories below 1800 per day. |
04/09/2025
| Implemented |
| 6500.135(a) | Individual # 1 was given Corcidin HBP on 01/31/24 and 02/02/25 and Robitussin on 02/04/25. There is no record of a prescription for these medications. | A prescription medication shall be prescribed in writing by an authorized prescriber. | On 4/4/2025, the OTC medication form was taken to the PCP for review and authorization signature to ensure that individual #1 receives medications prescribed by an authorized prescriber. |
04/09/2025
| Implemented |
| 6500.136(a)(2) | The PRN MAR lists Tylenol, Corcidin HBP, Robitussin and Azithromycin as being administered, however the Name of the Prescriber for each medication is not identified. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | On 4/8/2025, the lifesharer provider and the Lifesharer specialist reviewed the PRN MAR to ensure it included the name of the prescriber for each PRN medication (attachment #3). |
04/09/2025
| Implemented |
| 6500.136(a)(4) | The PRN Medication Magnesium 30 ml by mouth every 8 hours as needed for nausea and abdominal discomfort which was at the home during the physical site walk through was not included on the PRN MAR. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | On 4/8/2025, the lifesharer provider and the Lifesharer specialist reviewed the PRN MAR to ensure the Magnesium Hydroxide 30 mL PRN medication was on the MAR (attachment #3). |
04/09/2025
| Implemented |
| 6500.136(a)(7) | Individual # 1 is prescribed Aspirin 81mg as written on the pharmacy label. The medication record lists the dosage as 31 mg. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | On 4/1/2025, the lifesharer provider corrected the transcribed Aspirin on the MAR to have the dose match the pharmacy label that reads 81mg (attachment #3). |
04/09/2025
| Implemented |
| 6500.136(a)(9) | Individual # 1 is prescribed Metformin. The pharmacy label reads 1 Tablet (1000mg total) by mouth twice a day with breakfast and dinner. The medication record does not include the phrase "With breakfast and dinner". | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | On 4/1/2025, the lifesharer provider corrected the transcribed Metformin Tablet (1000mg total) by mouth twice a day with" breakfast and dinner" (attachment #3) |
04/09/2025
| Implemented |
| 6500.136(a)(10) | The PRN MAR indicates that Individual # 1 was given Corcidin HBP on 02/02/25, but the time of administration was not recorded or indicated. Similarly, Individual # 1 was given Robitussin on 02/04/25 but the time of administration was not indicated. The MAR reads "before bed". | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | The PRN MAR was revised to include the date, time of administration, the dose and medication, the reason and the time of recheck and results, to ensure all information is reflected on the MAR including times of administration (attachment #3) |
04/09/2025
| Implemented |